Are the Current Guidelines for Performing Sports With an ICD too Restrictive?

Theresia A M Backhuijs; Hilde Joosten; Pieter Zanen; Hendrik M Nathoe; Mathias Meine; Pieter A Doevendans; Frank J G Backx; Rienk Rienks

Disclosures

Br J Cardiol. 2016;23(1):16-20. 

In This Article

Abstract and Introduction

Abstract

Current guidelines recommend against vigorous sports for all patients with an implantable cardioverter defibrillator (ICD). In this study, we established the risk of life-threatening arrhythmias and shocks in patients with an ICD participating in sports.

In this single-centre, cohort survey with 71 patients (59% male) ≤40 years old at ICD implantation and with a left ventricular ejection fraction (LVEF) ≥35%, 16 patients were defined as athlete (exercise ≥5 hours per week). Sports-related and clinical data were obtained using questionnaires and medical records. Median age was 38 years (19–53 years). Median follow-up period was 67 months (11–249 months). Idiopathic ventricular fibrillation (VF) was the most frequent indication (20%) for implantation. There were 22 patients (31%) who experienced 127 shock episodes, of which 112 were appropriate: 15% of shocks occurred during physical exercise. Shocks did not occur more frequently in athletes (25%) compared with non-athletes (33%, p=0.760). Intensity of exercise and appropriateness of shocks were not associated.

In conclusion, we found no evidence that participation in sports contributed to the risk of life-threatening arrhythmias and (in)appropriate ICD shocks in patients with an ICD. In individual cases, the advice to participate in sports could be more lenient compared with current guidelines.

Introduction

An implantable cardioverter defibrillator (ICD) is used for primary and secondary prophylaxis in the treatment of life-threatening arrhythmia. Guidelines for ICD patients, originally published in 2005, advise against any competitive sports more vigorous than 'Class IA' activities such as bowling or golf.[1] American College of Cardiology (ACC)/American Heart Association (AHA)/European Society of Cardiology (ESC) embraced this advice stating "for legal and ethical reasons athletes receiving cardiovascular drugs and devices such as pacemakers and ICDs are generally not allowed to participate in high-grade competition."[2] For leisure-time sports, Heidbuchel et al. allow exercise from six weeks after an ICD implantation with assessment of expected maximal sinus rate and/or preponderance for atrial fibrillation with prophylactic institution of antiarrhythmic or bradycardic therapy.[3]

The postulated risks on which these restrictions are based, are, first, increased risk of defibrillator shocks, both appropriate and inappropriate, and, second, potential failure of a shock to convert a life-threatening arrhythmia. Competing athletes have an increased adrenergic tone, which may reduce the efficacy of defibrillator shocks. Third, in some sports, such as weightlifting and golf, repetitive arm-motion can induce excessive stress on lead systems. Contact sports have a risk of device and lead damage.[4] Finally, adverse events have been reported due to arrhythmia or shock during sports participation, for instance falling from a bicycle while having an arrhythmia treated by an ICD shock.[4]

Young athletes with an ICD and preserved left ventricular function are often caught between the passion to continue their sport and the guidelines, which are felt to be too restrictive. At the heart of this dilemma is a lack of evidence about the natural history of athletes with an ICD participating in (competitive) sports. As there are no prospective data in elite athletes with ICDs, the current guidelines are based on realistic, albeit largely theoretical, considerations without the essential level-of-evidence classifications. Evidence is needed to guide these patients, their families and physicians to make an informed decision about sports participation.

To address this issue, we performed a retrospective single-centre cohort survey in which the primary end points were to establish:

  1. Whether participating in sports for patients with an ICD is related to an increased risk of untreatable ventricular arrhythmias.

  2. Whether athletes with an ICD received more frequently appropriate shocks compared with non-athletes.

Additionally, the following secondary end points were addressed:

  1. Is the intensity level of the sport related to the initiation of ICD shocks?

  2. Is there an association between the indication for ICD implantation (diagnosis, primary or secondary prophylaxis) and the occurrence of (in)appropriate shocks?

  3. Are certain sport activities more likely to induce life-threatening arrhythmias?

  4. What is the risk of damage to the cardioverter device during physical exercise and does this result in an increased risk of receiving (in)appropriate shocks?

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